Keeping tabs on patient notes
Time and time again we are told of the importance of record keeping and perhaps it is right firstly to consider why we need good records. The British Dental Association (BDA) sees record keeping as fulfilling the following purposes:
- patient safety
- probity enquiries
- evaluation of treatment.
However, the General Dental Council in its Standards for dental professionals is more vague, stating only: “Make and keep accurate and complete patient records, including a medical history, at the time you treat them. Make sure that patients have easy access to their record.”
In discussions with dentists over the years, it is clear that many will admit to deficiencies in the past when recording some of the information that we now accept should help comprise a good clinical record. Very often time is cited as the reason; sometimes dentists only see positive findings as requiring any detail. Whatever the reason, it is clear that it is our responsibility to maintain good contemporaneous and complete notes from clinical encounters.
This incompleteness of clinical records is very much supported in the evidence we have available from published audits. In 2001, an audit looking at the records from 47 general dental practitioners entering the quality assurance programme of a private capitation scheme (BUPA) in England and Wales found various deficiencies1.
These records were examined by an independent assessor and measured against seven different domains for which a standard was identified (effectively one domain split into two separate further areas of interest giving eight domains). The domains were medical history, examination of soft tissues, full tooth charting, periodontal screening, at-risk periodontally and pocket depth chart (the separated domain), diagnosis and treatment planning.
The results showed dentists only to have achieved more than 50 per cent of target frequency of recording in one domain – full tooth charting (70 per cent). Completed medical histories were only available in 45 per cent of clinical records and, worst of all, nearly 80 per cent of patients had no periodontal screening at all.
Another audit from 2009 showed an improving picture but still with some deficiencies2. However, unlike the 2001 audit, the method employed in this study was self-assessment, which is largely dependent on how well-calibrated and rigorous the assessors were in applying the criteria. If, indeed, the quality of clinical records is improving, we have the defence societies and professional bodies such as the Faculty of General Dental Practitioners (FGDP) to thank for continually preaching the importance and assisting us in achieving a better standard.
The Lothian Record Keeping Audit
Other articles have presented a thoughtful case for incorporating clinical audit (and significant event analysis [SEA]) into everyday practice3,4. These sentiments have been similarly recognised by the Quality Improvement Team for Dentistry in Lothian (Lothian Committee for Quality in Dentistry – LCQD).
In April 2009, the committee commissioned an audit on clinical documentation standards that could be used by all dental professionals. This audit was to use the planned updated standards issued by the FGDP as the basis for the audit. The following year the protocol and data gathering tool were approved by LCQD for distribution to all dentists in Lothian. The remit was to produce an audit that:
- was comprehensive covering all aspects of record keeping
- set out the data sheet as a set of simple questions
- allowed the data gatherer to answer questions ‘yes’, ‘no’ or ‘not applicable’
- resulted in one overall figure for compliance.
Having looked at several audits and the data gathering tools that accompanied them, several points became apparent. Record keeping audits had concentrated on certain domains such as periodontal treatment and medical histories. While using a domain-focused audit can be very useful, it would appear to miss the important first step of analysing all areas of record keeping which might be overlooked e.g. quality of referral letters, details of surgical procedures, etc. This approach can also be messy as there are different results for different domains. Having a single compliance figure overcomes some of these problems.
In developing the Lothian audit data gathering tool it was decided to leave it simple with each ‘yes’, ‘no’ or ‘not applicable’ answers carrying the same weight and total compliance expressed as a percentage. It should be stressed at this juncture that before embarking on any audit an acceptable standard needs to be set by those involved in the project. This is up to the individual practitioner to decide, but in the pilot studies the target for round one was set at 80 per cent and round two at 90 per cent.
An example of the data gathered is shown in figure one. This shows the information split into several questions which require a ‘yes’, ‘no’ or ‘not applicable’ answer. Changing any of the answers will automatically change the totals at the bottom of each column which are then used to calculate the total compliance.
Totals for each patient record audited can then easily be transferred to a results summary sheet (Fig 2). By completing the results electronically, calculation can be made for each data sheet based on a compliance figure (Yes/Yes + No x 100 per cent). When all 25 patient records are complete, an overall compliance figure for all patients can be attained.
All audits suffer to some extent from not weighting the data by importance. For example, would having a dog-eared written record card equate in importance to not having a current medical history – probably not?
However, further refinements of the audit in future might allow weighting to be applied to the results and this would be a relatively simple tweak to incorporate into the data collection tool. It would be possible with this audit to adapt it further and weight each answer according to a system of desirable or essential outcomes. We hope this audit will continue to evolve and assist many dental practitioners for years to come!
This article first appeared in the Autumn 2011 issue of Summons
About the author
Dr Terry Simpson is a general dental practitioner and honorary research fellow at the University of Edinburgh. Terry would like to acknowledge the contribution of the Clinical Governance Support Team at NHS Lothian and, in particular, Denise Needham in constructing and promoting this audit. He would also like to acknowledge NCAAG (National Clinical Audit Group in E & W) which piloted the initial spreadsheet design.
1. Morgan RG. Quality evaluation of clinical records of a group of general dental practitioners entering a quality assurance programme. Br Dent J. 2001;191:436-41
2. Cole A, McMichael A. Audit of Dental Practice Record-Keeping: A PCT-Coordinated: Clinical Audit by Worcestershire Dentists. Primary Dental Care. 2009; 16:85-93
3. MacPherson D. A Job Worth Doing. Summons. Summer 2010;18-19
4. MacPherson D. Making a SEA Change. Summons. Autumn 2010;18-19
Obtaining a copy
Copies of the audit comprising instructions, protocol, data collection sheets (one per patient) and results summary sheets can be obtained, in electronic version only, by contacting Denise Needham at NHS Lothian (). Printed sheets can be made from these if the data gatherer prefers but the data collections sheets fit best on A3 sheets or alternatively several landscape A4 sheets.